Maternal and fetal cardiovascular indices during fetal hypoxia due to cord compression in chronically cannulated sheep. I. Responses to timolol

Pregnancy in chronic renal insufficiency and end-stage renal disease

Childbearing is important to women with renal disease, but pregnancy has generally been regarded as very high risk in these women. In this review, an attempt is made to clarify the nature and severity of those risks in the settings of chronic renal insufficiency and end-stage renal disease, including dialysis patients and transplant recipients. Hypertension is the most common life-threatening problem in all three groups. A wide range of antihypertensive medications have been used, with angiotensin-converting enzyme inhibitors the only drugs absolutely contraindicated because of their association with neonatal anuria, pulmonary hypoplasia, and neonatal death. Women with serum creatinine levels of 1.4 mg/dL or greater are at risk for accelerated loss of renal function compared with women who don't become pregnant. Transplant recipients have a risk for loss of renal function similar to controls as long as renal function is well preserved. The frequency of conception is decreased in women with renal insufficiency and markedly decreased in dialysis patients (0.5% per year). Return of fertility is the rule in transplant recipients. Exposure to immunosuppressive drugs, including prednisone, azathioprine, cyclosporine, and tacrolimus, has not been associated with an increase in congenital anomalies. These drugs, particularly cyclosporine, have been associated with small-for-gestational-age babies. Transplant recipients are at risk for infections that have implications for the fetus, including cytomegalovirus, herpes simplex, and toxoplasmosis. All groups have an increased risk for prematurity and intrauterine growth restriction. The percentage of pregnancies resulting in surviving infants in women with renal insufficiency and transplant recipients ranges from 70% to 100%. For women who conceive after starting dialysis, the likelihood of a surviving infant is approximately 50%.

Topical timolol therapy in pregnancy: is it safe for the fetus?

At 21 weeks of gestation, a 37-year-old woman was referred to our hospital. The fetus showed bradycardia and arrhythmia. Because of glaucoma the woman had previously been treated with timolol eye drops. In this paper a possible association between the timolol eye drops and the fetal cardiac arrhythmia is discussed.

Uterine and fetal hemodynamics and fetal cardiac function after atenolol and pindolol infusion. A randomized study

OBJECTIVE

To evaluate the short-term effects of intravenously given atenolol and pindolol on utero- and umbilicoplacental vascular impedance, fetal hemodynamics and cardiac function in patients suffering from pregnancy-induced hypertension.

STUDY DESIGN

A total of 24 women were randomized to receive atenolol or pindolol infusion. By using pulsed color Doppler techniques, uterine, placental arcuate, umbilical fetal middle cerebral and renal arteries were examined before, at the end and 30 min after the end of infusion. Pulsatility indices (PI) were calculated to assess vascular impedance. Fetal myocardial function was evaluated by using pulsed Doppler and M-mode echocardiography. Peak systolic velocities from the ascending aorta and pulmonary trunk, and also inner diameters and fractional shortenings of both ventricles were measured.

RESULTS

Both drugs significantly decreased maternal blood pressure. Immediately after the infusion, maternal heart rate was significantly decreased in both groups; but the decrease was clearer and lasted longer in the atenolol group. Pindolol caused no changes in utero- or umbilicoplacental vascular impedance, while atenolol increased it in the nonplacental uterine artery. After atenolol infusion, PI in the umbilical artery was higher than after pindolol. Pindolol had no effects on fetal hemodynamics, while atenolol decreased PI value in the fetal renal artery. Peak systolic velocity in the pulmonary trunk was decreased after atenolol. Pindolol did not affect the fetal cardiac function. In subgroups with originally increased utero- or umbilicoplacental vascular impedance, the responses in uterine and umbilical vascular impedance and in fetal hemodynamics and cardiac function after atenolol and pindolol were different compared to whole groups.

CONCLUSION

Differently acting antihypertensive agents seem to affect differently uteroplacental vascular impedance. Atenolol may have some direct effects on fetal hemodynamics and cardiac function. According to our results, pindolol seems to be more preferable in the treatment of pregnancy-induced hypertension than atenolol.

Pregnancy in women on haemodialysis and peritoneal dialysis

Pregnancy in women with renal insufficiency and end-stage renal disease, while uncommon, is definitely possible, and such women should not assume they are infertile. Contraception should be prescribed for those who do not want to conceive. For the woman who is dialysed during pregnancy, the risks can be minimized by aggressive blood pressure control and prompt diagnosis and treatment of bleeding episodes; however, no degree of vigilance can guarantee that a woman will not suffer any of the severe complications that have been described in pregnant dialysis patients. Intensive dialysis should be undertaken to maintain chemistries that are as nearly normal as possible, and premature labour should be treated with indomethacin. Our current state of knowledge suggests that the success rate of pregnancy in dialysis patients is no better than 52%. It remains to be seen whether CAPD and erythropoietin improve the currently poor outcome. While transplantation offers the best chance of child bearing for women with end-stage renal disease, transplantation is not always possible. Thus we no longer discourage women on dialysis from becoming pregnant as long as they understand that the likelihood of success is small and that serious risks are involved, and as long as they are willing to follow the time-consuming regimen we think it is necessary for their safety. We hope that, in time, increased experience with pregnant dialysis patients will lead to more successful outcomes and that the possibility of parenthood will be added to the improved quality of life in these women.

Maternal and fetal haemodynamics in hypertensive pregnancies during maternal treatment with intravenous hydralazine or labetalol

Intravenous treatment with 10 mg of hydralazine or 100 mg of labetalol was randomly allocated to 30 hypertensive pregnant women. Umbilical artery flow velocity waveforms were recorded using a pulsed Doppler duplex scanner (ATL Mk V) and umbilical artery pulsatility index (PI) and fetal heart rate (FHR) were derived from these recordings. Maternal blood pressure decreased significantly after both drugs. Maternal pulse rate increased after hydralazine but did not change significantly after labetalol. FHR did not change significantly after hydralazine but decreased after labetalol. PI decreased after hydralazine and increased after labetalol--most fetuses showed little change but a few in each group showed large changes in PI, as did two of five additional patients studied. We attributed the decrease in PI in some fetuses after hydralazine to vasodilation, and the increase in PI in some fetuses after labetalol to vasoconstriction in the fetoplacental circulation, suggesting that fetal beta-blockade may occur after maternal treatment with labetalol.

Pregnancy in organ transplant recipients

Pregnancy in women who are renal transplant recipients carries risks of hypertension and worsening of renal function for the mother and risks of prematurity, growth retardation, and infection in the infant. The risks for mother and child are greater if the transplant recipient has moderate renal insufficiency or hypertension prior to conception; even in patients with moderate renal insufficiency, birth of a viable infant is the rule. Pregnancy should not be discouraged in renal transplant recipients, but both mother and fetus should be carefully followed through the pregnancy and neonatal period. The restoration of fertility should be included as a benefit of transplant in discussions with young women deciding between dialysis and transplant for treatment of renal failure.

Maternal and fetal cardiovascular indices during fetal hypoxia due to cord compression in chronically cannulated sheep. II. Responses to promazine

Promazine (Sparine) administered to chronically cannulated pregnant ewes caused significant maternal and fetal tachycardia and hypotension, depressed uterine blood flow and fetal Pao2, and increased fetal Paco2. When the drug was given before brief compression of the umbilical cord, uterine flow was more depressed than by compression alone, the fetal pressor response was attenuated, and fetal posthypoxia tachycardia was augmented. We conclude that promazine taken by a mother could have especially deleterious effects on her fetus when the latter's oxygenation is already depressed (e.g., by cord compression), and suggest that the use of promazine during labor be reevaluated.